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Notes, Comments, and Abstracts.GARAGE ACCIDENTS.

WITH the growth of motoring has grown also the tale ofmotor accidents, and an inconspicuous but none the lessan important and interesting class of these take place inthe garage. A few garage accidents are caused by themishandling of electric current or by starting the enginewith the gear in, but the majority are due to poisoning byexhaust gases. Although motoring is thirty years old,and the first warning against the danger of running anengine in a confined space was published twenty years ago,a very small number even of professional drivers are awareof the deadliness of exhaust fumes. The reason for thisignorance is possibly that carbon monoxide, the lethalconstituent of these fumes, kills without leaving any obvioustrace, and many garage deaths are wrongly ascribed toapoplexy. The presence near the body of gastric contentsis likely to mislead the police or local practitioner intosuspecting an alcoholic condition, and the symptoms, ifobserved, support the mistake. In other cases epilepsyand petrol poisoning are wrongly suggested as causes ofdeath. The gases are the product of the imperfect com-bustion of hydrocarbons, and the worse the combustionthe greater will be the output of CO, which with CO 2constitutes the bulk of the fumes. A dangerous concentra-tion-according to some experiments 1 in 1500-mayeasily be reached in narrow lanes, corners, and roofedspaces. When an engine is run in a small closed shed itproduces a high concentration at once, especially if thecarburetter air vent is closed or nearly so. As much as11 per cent. is reached in a few minutes, but before thisoccurs the driver, if he has been imprudent enough to shuthimself in with the car, is dead. Even coal gas, at itsworst, contains no more than 5 to 10 per cent. of CO, andno one would stay in a kitchen with unlighted gas streamingfrom the oven jets, but he would be safe there comparedwith the car owner working on a running engine in a smallgarage. CO is the deadlier for being odourless and colour-less. A concentration of 1 in 1000 or 1 in 2000 will saturatethe blood in an hour or less to the 60 per cent. or so atwhich death occurs. Even as minute a trace in the atmo-sphere as 1 in 5000 will produce headache, malaise, andunsteadiness of the legs in two to three hours. As mightbe expected, therefore, 3 per cent. will produce symptomsof acute poisoning in a quarter of an hour, and less if thesubject is working hard. The safety limit in Americanmines is held to be 1 in 5000. Besides poisoning the air,a running engine quickly uses up the oxygen. The con-centration is heaviest at first just at the end of the exhaustpipe, and the owner moving to and fro stirs the mixture.He notices nothing for a time, but then suddenly, especiallyif he happens to take a deep breath of an extra strongconcentration, he feels a violent headache, a loss of balance,and a deadlv weakness at the knees. His efforts to breathemake matters worse, and, sinking to the floor where thefumes are heaviest, he soon succumbs. Many professionaldrivers are familiar with the beginning of this syndrome,but few treat it with the importance it deserves.

Dr. J. Dettling!, of the Medico-Legal Institute of Zurichrniversity, has been studying the question from the pointof view of public security, and has suggested certain pre-cautions which should, if given the status of law, minimisewhat is undoubtedly a growing public danger. He pro-poses that every place where cars are stored should havepermanent and ample communication with the outside air,such as large unclosable ventilators. This will excite thewrath of owners by forcing them to empty their radiatorsevery night in winter, but that cannot be helped. Further,the running of an engine in a small garage should, he suggests,be absolutely forbidden, as poisoning can occur even withopen doors and windows. It should be obligatory to postan official warning in all garages. Real and lastingprophylaxis, however, can only be undertaken by physician,sanitary official, architect, motorist, and chemist workingin cooperation.

SANOCRYSIN IN PULMONARY TUBERCULOSIS.

A PAPER on the immediate results of treating pulmonarytuberculosis with sanocrysin appears in the Semana Medicaof Oct. 7th. The authors, Dr. E. M. F. Rey, Dr. F. E.Boneo, and Dr. Priam, give the results of treatment infifty cases which had not been benefited by previous carein a sanatorium. They are not very enthusiastic aboutthe results, which, they say, were " not so favourable asthey could have wished." Of the 50 treated, 33 improved,whose state without sanocrysin might have remainedstationary or got worse ; 12 remained the same, 3 died,

1 Schweiz. Woch., August 26th, p. 832.

and 2 were worse. On their face value these figures appearsatisfactory, and justify the authors’ opinion that sano-

crysin, with other gold preparations, should be consideredas a weapon in the antituberculous armoury, pendingfurther improvements in their preparation and use. Theymention a case of acute miliary tuberculosis in which" unexpected results " followed treatment, but they giveno details, and unfortunately do not include a descriptionof it in their list.

PRACTICAL JOKES WITH COMPRESSED AIR.WITH the ever-increasing use of high-pressure air for

drills, riveters and industrial cleaning, more and more menare being brought in to first-aid stations with rupture of thebowel. Considering the amount of compressed air that isused in this country it is rather surprising that clinicalaccounts of these accidents all seem to appear in foreignpublications. The disaster is generally due to the misguidedhumour of a fellow worker who has thought that it would bean excellent joke to inflate his unsuspecting companion perrectum. The first case, mentioned by Dr. G. W. Stone, ofLondon, is the only one on record in which the nozzle of thehose was believed actually to have been inserted in theanus. Drs. F. B. Block and M. I. Weissman described atypical case, in the Journal of the American Medical Associa-tion for May 22nd, in which the patient had a tear an inchlong at the junction of the rectum and sigmoid. The columnof air had forced itself through several layers of clothingand the two sphincters although the nozzle was held aninch or more away from the body. Dr. A. W. Andrews 1

gave a reasonable explanation by pointing out that air at apressure of 100 lb. or over forms a solid column severalinches long in front of the nozzle, while the floor of thepelvis, owing to its peculiar construction, constitutes a

funnel with the anus at its apex. The involuntary contrac-tion of the levator and sphincter narrows and deepens thefunnel, assisting the air to enter the bowel. Moreover, it

only requires a pressure of 7 to 12 lb. to rupture theintestinal wall. The most recent review of the subjectappears in the same journall for October last, whereDr. George L. Hays records 32 cases culled from medicalliterature. No doubt there are many observations whichare never reported. Dr. Hays also mentions a report byPetrin2 of a fatal accident which was caused by a workmantrying to shut off pressure by kinking the hose and thenholding the end between his teeth. He slipped and relaxedhis hold, and the air stream ruptured his oesophagus.The condition of rupture of the bowel is not hard todiagnose, as the abdomen is enormously distended and istympanitic all over, and the history will reveal the connexionwith high-pressure air. It ought to be possible to preventall but a very few of these accidents by the systematicpublication of oral and printed warnings, in which attentionis called to the fact that the nozzle of the apparatus neednot actually be in contact with the body to produce seriousinjury. The most effective treatment is emergency punctureand early laparotomy. The sigmoid is usually the site ofthe rupture, for the anus and rectum escape injury becauseof their outside support.

COLDS AND CHILL.SOME years ago Mr. Alexander Francis 3 said that in

nine cases out of ten a chill is the exciting cause of aninfective catarrh, and suggested that what usually liesbehind the chill is an unstable vasomotor system. Withsuch instability, he said, a draught or sudden change oftemperature produces a localised vaso-constriction, witha compensatory vaso-dilatation elsewhere. If this area ofdilatation happens to be in the mucous membrane of thenaso-pharynx or bronchial tubes "it provides, as it were,an incubator for the organisms lurking there, which suddenlybursts into activity and a catarrh results." A similarsuggestion has now been put forward in France by Dr.Jean Tarneaud who, while accepting the infective originof colds, believes that the causal factor in the vast majorityof cases is a shock to the vegetative nervous system causedby a sudden change in temperature. This shock, he considers,causes a reflex vasomotor disturbance of the nasal mucousmembrane, which disturbance " allows the infective elementto come into play." The arguments put forward in supportof his contentions are the general liability to colds at timesof sudden change in the weather, the special liability ofcertain persons to them after any exposure to cold, and thefact that a congestion of the nasal mucous membrane isthe invariable first sign of an attack. Dr. Tarneaud claimsthat the only effective prophylactic treatment is that whichaims at lessening the sensitiveness of the nervous systemto shock and of the nasal mucosa to vascular disturbances-i.e., general hygiene aiming at desensitisation to cold-and

1 Surgery, Gynæcology, and Obstetrics, January, 1911, xii., 63.2 Beitr. z. Klin. Chir., 1908, lxi., 265.

3 Brit. Med. Jour., 1919, ii., 223.4 Paris Médical, Sept. 4th, 1926.

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the local use of the galvano-cautery. The only drugs whichare useful, he thinks, are those which affect the vegetativenervous system, such as adrenalin, aconite, and belladonna.These suggestions are interesting, but it has to be

remembered that the local vascular dilatation which theseobservers believe to be so harmful in favouring the growthand penetration of pathogenic germs is the natural responsethroughout the body to microbic infection. From this itmight be assumed to be a defence rather than a source ofweakness, and, in fact, we are taught that the increasedsecretion helps to wash away germs while the increasedblood-supply dilutes the toxins and increases the phagocyticdefences. And yet it must be admitted that chronic, asopposed to acute, congestion does favour microbic invasionas the beneficial results of removing such congestion byvarious local operationestify. Probably there are manydifferent types of cold, from the undoubtedly infectiousones which occur in epidemics to the transient rhinorrhceawhich afflicts sensitive people after the slightest chilling.It is the first of these on which emphasis is laid, for example,in Prosser White’s monograph on Catarrhal Fevers, whilstthe second seems to be the type which has chiefly comeunder the notice of Dr. Tarneaud.

CONTRACEPTION BY SPERMATOXIN.Dr. S. S. Rosenfeld, adjunct gynaecologist and obstetrician

at the Lebanon Hospital, New York, has carried out someinteresting experiments on the production of a spermatoxinin human beings immunised with injections of living sperma-tozoa. The preliminary report appears in the AmericanJournal of Obstetrics and Gynecology (vol. xii., No. 3).Three women received repeated injections of human semen,but in no case was a spermatoxic reaction subsequentlydemonstrable in the serum. Negative results were obtainedafter the use of both living and dead spermatozoa. It has,of course, been claimed that women who have been injectedwith semen can avert pregnancy for about 20 months, thetemporary sterility being due to the production in their bloodof a spermatoxic antibody. If this is correct a new contra-ceptive method would become available for women in whompregnancy is contra-indicated. Dr. Rosenfeld’s resultsappear, however, to throw doubt on these statements.At any rate in the light of his experience many injections ofsemen would appear to be necessary in order to obtain atemporary sterility, so that as a practical contraceptivemethod immunisation with injections of semen need not beconsidered very seriously.

AN INSURANCE COMPANY’S NURSING SERVICE.

IN 1924 the Mutual Property Insurance Company, Ltd.,of London, instituted a free nursing service for the benefitof its sickness and accident policy-holders. These people,who are mainly of the industrial classes, received attentionand advice at the hands of a nursing sister, who visitedher patients by car. As more and more patients began totake advantage of the service, it was found impossiblefor a single visiting nurse to carry on the work. In April,therefore, the service was reorganised, and the policy-holders, instead of receiving visits from the Company’snurse, are now attended by members of 96 district nursingassociations with which the Company has become affiliated.The cost of the visits is entirely defrayed by the Company,and the policy-holders naturally receive more promptattention than was formerly possible.

Since this nursing service was started in 1924, nearly9000 visits have been made ; the fact that 1100 of thesewere made during September last shows that the scheme isgrowing in its scope. In connexion with this welfare work,the Mutual Property Insurance Company has distributedover 300,000 folders and leaflets dealing with personalhealth.

COOPERATIVE BABY CARE.THE little book,

" To Wives and Mothers," published bythe National League for Health, Maternity, and ChildWelfare, has long been recognised as a useful guide in thedaily task of caring for children and in facing the commondifficulties which arise in most homes where there is a youngfamily. The eighth edition has just been published underthe new title " To Mothers and Fathers."1 As the newchapter on a Father’s Duty only occupies two and a halfpages, it is evidently intended that the father, equally withthe mother, should acquaint himself with the earlier chapters ;lie is indeed specially recommended to study the sectionon the expectant mother, to make sure that all properprecautions are being taken and preparations made for thesafeguarding of his wife and the coming child. His responsi-bility in giving the baby the best chance, by keeping therules of the game, is also emphasised, as in the sentence :

1 To Mothers and Fathers. How to Keep Yourselves and YourChildren Well and Strong. National League for Health, Maternity and Child Welfare, 117, Piccadilly, London, W. 1. 6d., post free.

" Regular feeding will only be possible if you help ; if youare out with your wife you must make it your duty to bringher home in time for baby’s feed."The preface expressly states that the booklet is not

designed to replace medical and other expert advice avail-able at a welfare centre, but it contains in its 79 pages,a remarkable amount of homely counsel on the well-being-of the expectant and nursing mother, on many aspects of’child-care up to the age of 5, and on home management,.as well as sound hints on the nursing of various illnesses,.and the avoidance of spreading infection. The table onp. 64, setting out the period of incubation, of quarantine,.and the time when the patient may be regarded as free-from infection after the commonest infectious diseases, isespecially useful. The few misprints scarcely mar a well-balanced and carefully compiled pamphlet.

WEIGHTS AND MEASURES,

To the Editor of THE LANCET.

SIR,—Old table books tell us that apothecaries mix theirmedicines by apothecaries’ weight, but buy and sell theirdrugs by avoirdupois weight. The apothecaries’ drachmis 60 grains, and the avoirdupois dram 27 grains ; theapothecaries’ ounce 480 grains (precisely the weight of5s. 6d. in silver) ; the avoirdupois ounce 437 grains(practically the weight of 5s. in silver). If a scruple is askedfor, it is distinctly 20 grains (practically the weight of a3d. bit) ; but if a drachm or dram (the sound is the same)or an ounce is demanded, what is supplied over the counter,retail or wholesale ? If the demand is in writing, and theapothecaries’ symbol for drachm or ounce prefixed, Ipresume that 60 or 480 grains are supplied, and if dr. oroz. is prefixed, 27 or 437 grains are supplied. But whereambiguity arises, is it left to the discretion of the serverhow many grains to supply ? I have been told that theBritish Pharmacopoeia of 1864 changed the weights andmeasures from apothecaries’ to imperial, and that theapothecaries’ symbols were then applied wrongfully toavoirdupois weights and measures.

I am, Sir, yours faithfully,London, Nov. 5th, 1926. PERTINAX.

A DOUBTFUL COMPLIMENT.

A PHYSICIAN attached to an important hospital sends usthe following letter recently received from a patient:-DEAR SIR,—Please excuse my writing to you, but could you

tell me which hospital I could see you at, or the lowest feeyou accept. My poor brother came to see you but it cost him£2 2s. I could not possibly pay that as I do not possess it.I am suffering something awful with my head particularlywhen the menses are on. I am a married woman with threechildren. My husband is a carpenter. I have already undergonean operation for gall-stones, and I pray to God to be able tosee you. If only you could tell me this dizziness is due to myliver it would put a new lease on my life. I don’t want to seeanyone but yourself. After what you said of my brother, Ihave faith in your very name. I have a bald patch on the leftside of my head and it seems as if my head is always in a vice,and it affects my eyes. Four years ago next month, my brothercame to see you on a Monday, and died on Friday 6 o’clock inthe same week. Hoping and praying you will see me. Thankingyou in anticipation. I remain, yours faithfully,

A. B.

PUBLIC HEALTH IN SEYCHELLES.

Mr. J. L. Devaux, Administrator, reports that the popula-tion of the colony on Dec. 31st, 1924, was estimated at25,847, an increase of 1324 since the census of 1921. Therewere 178 marriages during the year, or 70 more than in1923. The births number 723, corresponding to a rate of29-97 per 1000. The deaths totalled 378, or 14-62 per 1000.The estimated number of square miles comprised in theSeychelles islands and dependencies is 156. Mahe is thelargest and most populous island and is distant fromMauritius 934, from Madagascar 600, and from Zanzibar970 miles. It is mountainous, fertile, and has an area ofabout 55 square miles. The climate is quite healthy, and,owing to the absence of the anopheline mosquito, malariadoes not occur. The maximum shade temperature rarelyexceeds 86°, but even at night the temperature seldomfalls below 74°. The rainfall averages about 90 inches,although in some years it has reached 115 inches.

Corrigendum.—In the discussion on the Management ofContracted Pelvis at the Harveian Society (THE LANCET,Nov. 13th, p. 1010), Dr. G. de Bec Turtle should have beenreported as saying that Walcher’s position was of somevalue in increasing the size of the inlet in cases of flat pelvis,and that in the high forceps operation it was best to removethe instruments after bringing the head down into the pelviccavity.